Angiographic Pitfalls of Pulmonary Arterial Interventions

Purpose: As catheter-directed treatment (CDT) is implemented for massive and submassive pulmonary embolism (PE), there may be pitfalls associated with the therapeutic angiographic procedure that may impact the study interpretation and procedure success. We report three cases in which the angiographic findings prompted a closer look for correct interpretation and certain pitfalls were identified.

Materials and Methods: Notable angiographic pitfalls during pulmonary arterial intervention include catheterization through a patent foramen ovale; catheterization into the coronary sinus with angiography mimicking right ventricular venous outflow; and inadvertent catheterization of anomalous pulmonary arterial anatomy during thrombectomy, resulting in pseudoaneurysm.

Results: Case 1: A 46-year-old woman with massive PE was referred for CDT. After advancement into the presumed right pulmonary artery during catheterization, angiography revealed the vessel to be the right inferior pulmonary vein. As the catheter was retracted, contrast was noted to outline the aorta. Further retraction into the IVC raised the possibility of an intracardiac shunt as opposed to femoral artery access. An echocardiogram performed the subsequent day revealed a right-to-left shunt. Case 2: A 65-year-old man diagnosed with submassive PE was referred for CDT. During catheterization, contrast injection showed the catheter to be in the coronary sinus, mimicking right ventricular outflow. The catheter was retracted and positioned correctly with subsequent successful thrombectomy. Case 3: A 76-year-old man diagnosed with massive PE was referred for CDT. During aspiration thrombectomy, one of the left lower lobe segmental branches was repeatedly manipulated. After the procedures, the patient developed hemoptysis. Subsequent computed tomography imaging revealed a left lower lobe pseudoaneurysm originating from one of two superior segmental branches of the anomalous six left lower lobe pulmonary segmental arteries. The pseudoaneurysm was subsequently coiled successfully.

Conclusions: The implementation of CDT for PE as well as other angiographic pulmonary catheter treatments mandates increased awareness of potential pitfalls during angiography.